Comprehensive Health History & Physical Exam

Comprehensive Health History & Physical Exam Student’s Name: Institution Affiliation: Student (s) Name (s):__________________Date:__________ Client: Age__28_____ M/F_____F____ Ethnicity__African American____ CC Complaint Ms. Tina Jones reports to the healthcare facility seeking complete health assessment for a pre-employment requirement. She is a 28 year old single woman of African-American ethnicity presenting as the source of this particular history. From the case, she offers information freely in absence of contradictions. Her speech is clear and also coherent, talks while maintaining eye contact during the entire interview session. Her sitting posture is upright, alert and oriented with no sign of distress. History of Present Illness (HPI) The patient requires a pre-employment physical examination having acquired a new employment at the Smith, Stevens, Stewart, Silver and Company for her to commence the employment. Four months ago, she had received a yearly gynecologist exam at Shadow Health Clinic whereby she was diagnosed having polycystic ovarian syndrome (PCOS). As a result, she was prescribed to use oral contraceptives which have been effective. She has a history of type 2 diabetes which she maintains using metformin medication, diet and some exercise. She started this particular medication five months ago and there are no side effects that she has experienced. She considers herself to be in good health. Also, she reports that she is in a position of taking care of herself compared to the past and asserts that she is ready for the new job. Medical History (PMH, FH, Psychosocial, Genetic) Ms. Jones reports that she is up to date with all immunizations inclusive of childhood examinations. Last year, she had a tetanus vaccination with a booster. When asked of annual flu vaccinations, the patient denies. She reports of having diabetes history that she has been controlling with exercise, diet and medication. She monitors her blood sugar level on a daily basis; the last reading was 91 mg/dl. Re ………………………………………….CONTINUED……………………………………….